Provider Demographics
NPI:1700259173
Name:CROSSROADS HEALTH & COSMETIC CENTER PC
Entity type:Organization
Organization Name:CROSSROADS HEALTH & COSMETIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP-BC, FNP-C
Authorized Official - Phone:574-891-4920
Mailing Address - Street 1:21764 OMEGA CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-7809
Mailing Address - Country:US
Mailing Address - Phone:574-891-4920
Mailing Address - Fax:574-891-4902
Practice Address - Street 1:21764 OMEGA CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7809
Practice Address - Country:US
Practice Address - Phone:574-891-4920
Practice Address - Fax:574-891-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-07
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002933A363LA2100X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty